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MODIFIED LEARNER ENROLLMENT AND SURVEY FORM
THIS FORM IS NOT FOR SALE
Instructions:
1. This enrollment survey shall be answered by the parent/guardian of the learner.
2. Please read the questions carefully and fill in all applicable spaces and write your answers legibly in CAPITAL letters. For items not applicable,
write N/A.
3. For questions/ clarifications, please ask for the assistance of the teacher/ person-in-charge.
A.
GRADE LEVEL AND SCHOOL INFORMATION
A1. School Year 2 0 2 1 - 2 0 2 2 A2. Check the appropriate boxes only No LRN / With LRN A3
.
/ Returning (Balik-Aral)
A4. Grade Level to enroll:
GRADE 12
_______________________
A7. Last School Attended:
DON RAMON E. COSTALES MEMORIAL
NATIONAL HIGH SCHOOL A8. School ID: 300308
____________________________________ ___________________
A11. School to enroll in: DON RAMON E.
COSTALES MEMORIAL NATIONAL HIGH
SCHOOL A12. School ID: 300308
________________________________________ __________________
A5. Last grade level completed:
GRADE 11
_______________________
A9. School Address: GEN LUNA ST.
POBLACION ZONE II VILLASIS PANG.
___________________________________________________________
A13. School Address: GEN LUNA ST.
POBLACION ZONE II VILLASIS PANG.
_______________________________________________________________
A6. Last school year completed:
2020-2021
_______________________
A10. School Type:
/ Public Private
FOR SENIOR HIGH SCHOOL ONLY:
A14. Semester (1 st /2 nd ): A15. Track: A16. Strand (if any): STEM
____1st______________________ _____ACADEMIC TRACK_________________________ _____________________________________________
B. STUDENT INFORMATION
B1. PSA Birth Certificate No. (if
available upon enrolment)
B2. Learner Reference
Number (LRN)
1 0 2 1 2 5 0 9 0 0 8 5
B3. LAST NAME L U Q U I N G A N
B4. FIRST NAME J O H N P A U L
B5. MIDDLE NAME
H I B O
B6. EXTENSION NAME e.g. Jr., III (if applicable) __________________________________________________
B7. Date of Birth
(Month/Day/Year)
0 4 / 1 8 / 2 0 0 4
B8. Age 17 B9. Sex / Male Female
B10. Belonging to Indigenous Peoples (IP)
Community/Indigenous Cultural Community
Yes / No
B11. If yes, please specify: ________________
B12. Mother Tongue: TAGALOG_____________________
B13. Religion: ROMAN CATHOLIC_____________________
B18. Email Address: [email protected] _______________
ADDRESS
B19. House Number and Street B20. Subdivision/ Village/ Zone B21. Barangay
0408 SAN HILARIO ST.